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Naloxone Reporting Form

  1. Use of Naloxone During Emergency Drug Overdose
  2. Has person been treated with Naloxone by this agency in the past?*
  3. Location of Use / Location of Overdose
  4. Overdoser Information
  5. Gender
  6. Race / Ethnicity
  7. Overdose Signs / Symptoms Exhibited
  8. Actions Taken
  9. Was rescue breathing performed?
  10. Was AED utilized?
  11. Was CPR initiated?
  12. Did the overdoser survive?
      1. Additional Information
      2. Leave This Blank:

      3. This field is not part of the form submission.